Initial Comments:
Based on the findings of an unannounced onsite state licensure complaint survey completed February 28, 2024, Right at Home Northampton County was found not to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Chapter 51, Subpart A.
Plan of Correction:
51.3 (g)(1-14) LICENSURE
NOTIFICATION
Name - Component - 00
51.3 Notification
(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.
Observations:
Based on review of the agency incident reports and an interview with the agency Office Manager, the agency failed to notify the Department, via the Pennsylvania Department of Health Event Reporting System (ERS), of alleged consumer abuse, for one (1) of one (1) incident reports reviewed (Incident Report #1).
Findings Include:
A review of the agency incident/complaint documentation on 02/27/24 revealed the following:
Incident Report #1: Documentation provided of agency being notified by the granddaughter of (Consumer #4) of alleged consumer abuse on 09/09/23. (Family member) stated (Consumer #4) told her (Employee #4) wrapped a phone cord around her hands because she was trying to get up. No documentation of the agency reporting the incident to the Department of Health via the ERS. Documentation provided of the agency conducting an investigation.
An interview conducted with the agency Office Manager on February 27, 2024 at approximately 1:30 p.m. and email correspondence with the Office Manager on February 28, 2024 at approximately 10:48 a.m. confirmed the above findings.
Plan of Correction:Right at Home entered the incident/complaint into the DOH ERS on 03/14/2024 reporting/explaining the event/incident that occurred on 09/09/2023.
Right at Home will create a new policy/checklist to include adding a column for the PA Dept of Health Event Reporting System (sais.health.pa.gov/incidents/facilitylogin.asp) to our complaint management/incident reporting system.
The agency administrator will monitor the incident reporting/complaint management system (log sheet) on a quarterly basis to ensure proper documenting and reporting.
Initial Comments:
Based on the findings of an unannounced onsite state licensure complaint survey completed February 28, 2024, Right at Home Northampton County was found not to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 611, Subpart H. Home Care Agencies and Home Care Registries.
Plan of Correction:
611.51(a) LICENSURE
Hiring or Rostering Prerequisites
Name - Component - 00
Prior to hiring or rostering a direct care worker, the home care agency or home care registry shall: (1) Conduct a face-to-face interview with the individual. (2) Obtain not less than two satisfactory references for the individual. A satisfactory reference is a positive, verifiable reference, either verbal or written, from a former employer or other person not related to the individual that affirms the ability of the individual to provide home care services. (3) Require the individual to submit a criminal history report, in accordance with the requirements of § 611.52 (relating to criminal background checks), and a ChildLine verification, if applicable, in accordance with the requirements of § 611.53 (relating to child abuse clearance).
Observations:
Based on review of employee files and an interview with the agency Office Manager, the agency failed to conduct a face-to-face interview with the individual, prior to hire, for three (3) out of three (3) employee files (EF) reviewed (EF#1-EF#3).
Findings include:
A review of EFs was conducted on February 27, 2024 at approximately 10:30 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 02/01/24: No documentation provided of conducting a face-to-face interview. Documentation provided of a 'Interview Questionnaire' conducted on 01/29/24.
EF#2 DOH 10/13/23: No documentation provided of conducting a face-to-face interview. Documentation provided of a 'Interview Questionnaire' conducted. "Applicants Name', 'Date' and 'Interviewers Name', 'Date' sections left blank with no entries.
EF#3 DOH 12/08/23: No documentation provided of conducting a face-to-face interview. Documentation provided of a 'Interview Questionnaire' conducted on 12/06/23.
An interview conducted with the agency Office Manager on February 27, 2024 at approximately 1:30 p.m. and email correspondence with the Office Manager on February 28, 2024 at approximately 10:48 a.m. confirmed the above findings.
Plan of Correction:For EF 1, 2 and 3..staffing coordinator will bring them back into the office and reinterview them using the new "FACE TO FACE interview questions".
Staffing coordinator will conduct an audit of entire employee files to make sure all caregivers are found to be compliant with the "FACE to FACE intervew questons".
Right at Home has created a new form that specifies that the interview questions are done face to face at the time of the application is being filled out in the office.
Staffing coordinator will continue to audit caregiver files on a quarterly basis to ensure compliance.
611.54(a)(1) LICENSURE
Provisional Hiring
Name - Component - 00
The applicant shall have applied for a criminal history report and ChildLine verification, as applicable, and provided the home care agency or home care registry with a copy of the completed request forms.
Observations:
Based on review of employee files and an interview with the agency Office Manager, the agency failed to obtain a pending receipt of a criminal history report, prior to provisionally hiring, for one (1) out of two (2) provisionally hired employee files (EF) reviewed (EF#3).
Findings include:
A review of EFs was conducted on February 27, 2024 at approximately 10:30 a.m. Employee date of hire (DOH) is listed below.
EF#3 DOH 12/08/23: Per the agency Office Manager on 02/27/24 at approximately 12:30 p.m., this employee was hired provisionally, awaiting the results of a Pennsylvania State Police criminal record check. No documentation provided of a receipt of a pending criminal history report, prior to consumer contact. Employees first shift assignment with a consumer (Consumer #4) was on 12/08/23. Documentation provided of a Pennsylvania. State Police criminal record check dated 12/11/23.
An interview conducted with the agency Office Manager on February 27, 2024 at approximately 1:30 p.m. and email correspondence with the Office Manager on February 28, 2024 at approximately 10:48 a.m. confirmed the above findings.
Plan of Correction:EF1 and EF3 - criminal background checks have now come back and are completed.
Staffing coordinator will audit all caregiver files to ensure that all PATCH checks are completed.
Agency administrator has added a Right at Home Provisional hiring Policy and an attestation page will be given to any employee to sign that does not have a PATCH/FBI fingerprinting come back prior to their first shift with the company.
The agency administrator will audit (5 charts/files) on a quarterly basis to monitor that this does not occur.
611.54(a)(3) LICENSURE
Provisional Hiring
Name - Component - 00
The applicant shall swear or affirm in writing that the applicant is not disqualified from employment or referral under this Chapter.
Observations:
Based on review of employee files and an interview with the agency Office Manager, the agency failed to ensure the applicant did swear or affirm in writing that the applicant is not disqualified from employment, prior to provisionally hiring, for two (2) out of two (2) provisionally hired employee files (EF) reviewed (EF#1, EF#3) and the agency assigned the employee to a consumer prior to obtaining final results of the Pa state Police criminal check that stated results under review for one (1) of two (2) EFs. ( EF#1).
Findings include:
A review of EFs was conducted on February 27, 2024 at approximately 10:30 a.m. Employee date of hire (DOH) is listed below.
EF#1 DOH 02/01/24: Per the agency Office Manager on 02/27/24 at approximately 12:30 p.m., this employee was hired provisionally, awaiting the results of a pending Pennsylvania State Police criminal record check. No documentation provided of the applicant swearing or affirming in writing that the applicant is not disqualified from employment, prior to consumer contact. Employees first shift assignment with a consumer (Consumer #1) was on 02/06/24. This employee did not meet all of the requirements for a provisional hire. Agency received "Results under review" notice from the Pa. State Police and employee was assigned to care for consumer/s without first obtaining final results of the Pa. State Police criminal check.
EF#3 DOH 12/08/23: Per the agency Office Manager on 02/27/24 at approximately 12:30 p.m., this employee was hired provisionally, awaiting the results of a Pennsylvania State Police criminal record check. No documentation provided of the applicant swearing or affirming in writing that the applicant is not disqualified from employment, prior to consumer contact.
Employees first shift assignment with a consumer (Consumer #4) was on 12/08/23. This employee did not meet all of the requirements for a provisional hire.
An interview conducted with the agency Office Manager on February 27, 2024 at approximately 1:30 p.m. and email correspondence with the Office Manager on February 28, 2024 at approximately 10:48 a.m. confirmed the above findings.
Plan of Correction:EF 1 - criminal background check has come back and has since been terminated after the results of check came back. While they did not preclude her (legally) from employment the applicant did lie to company about her background check. EF 3 background check is back and complete.
Staffing coordinator will conduct an audit of all employee files to ensure all PATCH checks are completed.
Right at Home has implemented a new Provisional hiring policy and attestation page and it has been added to our computer tracking system.
The agency administrator will audit (5 charts) every quarter to ensure compliance.
611.56(a) LICENSURE
Health Screening
Name - Component - 00
(a) A home care agency or home care registry shall insure that each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, provide documentation that the individual has been screened for and is free from active mycobacterium tuberculosis.
Observations:
Based on a review of employee files and an interview with the agency Office Manager, the agency failed to ensure each direct care worker and other office staff or contractors with direct consumer contact, prior to consumer contact, was screened for and is free from active mycobacterium tuberculosis, in accordance with CDC (Center for Disease and Control) guidelines, for two (2) out of three (3) employee files (EF) reviewed (EF#2, EF#3).
Findings Include:
The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. (CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005; RR-17').(http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf.)
*Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19).
A review of EFs was conducted on February 27, 2024 at approximately 10:30 a.m. Employee date of hire (DOH) is listed below.
EF#2 DOH 10/13/23: No documentation provided of a baseline tuberculosis screening upon hire. Documentation provided of a single step TST on 12/06/23. No documentation provided of obtaining a second step TST.
EF#3 DOH 12/08/23: No documentation provided of a baseline tuberculosis screening upon hire. Documentation provided of a single step TST on 12/10/23. No documentation provided of obtaining a second step TST.
An interview conducted with the agency Office Manager on February 27, 2024 at approximately 1:30 p.m. and email correspondence with the Office Manager on February 28, 2024 at approximately 10:48 a.m. confirmed the above findings.
Plan of Correction:EF 2 upon better review DID have a 2 step TB test and has given the office the proper documentation of days administered and days results were read.
EF 3 was sent to restart the TB process over and she has since completed her first step and will go back for her 2nd step next week.
Staffing coordinator will audit all caregiver files to ensure the remaining caregivers are compliant.
Staffing coordinator will add another checklist (2nd step tb test complete date) to the computer system to ensure that this does not recur.
The staffing coordinator will audit 5 charts on a quarterly to make sure that this deficiency has not occurred again.
611.57(c) LICENSURE
Information to be Provided
Name - Component - 00
(c) Prior to the commencement of services, the home care agency or home care registry shall provide to the consumer, the consumer's legal representative or responsible family member an information packet containing the following information in a form that is easily read and understood: (1) A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services. (2) The hours when those services will be provided. (3) Fees and total costs for those services on an hourly or weekly basis. (4) Who to contact at the Department for information about licensure requirements for a home care agency or home care registry and for compliance information about a particular home care agency or home care registry. (5) The Department's complaint Hot Line (1-800-254-5164) and the telephone number of the Ombudsman Program located with the local Area Agency on Aging (AAA). (6) The hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry. (7) A disclosure, in a format to be published by the Department in the Pennsylvania Bulletin by February 10, 2010, addressing the employee or independent contractor status of the direct care worker providing services to the consumer, and the resultant respective tax and insurance obligations and other responsibilities of the consumer and the home care agency or home care registry.
Observations:
Based on a review of consumer files, the consumer admission packet, and an interview with the agency Office Manager, the agency failed to provide the consumer, prior to the commencement of services, the following: A listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry, for three (3) out of three (3) consumer files (CF) reviewed (CF#1- CF#3).
Findings include:
A review of CFs was conducted on February 27, 2024 at approximately 10:30 a.m. Consumer start of service (SOS) is listed below.
CF#1 SOS 02/06/24: No documentation provided of the agency providing the consumer a listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
CF#2 SOS 08/14/23: No documentation provided of the agency providing the consumer a listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
CF#3 SOS 01/17/23: No documentation provided of the agency providing the consumer a listing of the available home care services that will be provided to the consumer by the direct care worker and the identity of the direct care worker who will provide the services, the hours when those services will be provided, who to contact at the Department for information about licensure requirements for a home care agency/home care registry (717-783-1379), the Department of Health complaint Hot Line (1-800-254-5164), and the telephone number of the Ombudsman Program located with the local Area Agency on Aging, and the hiring and competency requirements applicable to direct care workers employed by the home care agency or referred by the home care registry.
An interview conducted with the agency Office Manager on February 27, 2024 at approximately 1:30 p.m. and email correspondence with the Office Manager on February 28, 2024 at approximately 10:48 a.m. confirmed the above findings.
Plan of Correction:CF1 + CF3 have been asked and signed stipulating that the have received our welcome pack which includes services to be provided to consumer, proposed hours for services to be provided, costs of proposed hours and all applicable phone numbers required, hiring /competency guidelines for our caregivers, disclosure to address direct care worker status as employees of our company as well as all insurance obligations and responsibilities of the consumer and our agency.
All consumer files will be audited and brought up to compliance.
Right at Home has created a new sheet that will be included in welcome packet outlining the above information and will be signed by all consumers (or their family).
Agency administrator will conduct an audit quarterly on at least 5 consumers to ensure that all paperwork is signed and dated by consumer.
Initial Comments:
Based on the findings of an unannounced onsite state licensure complaint survey completed February 28, 2024, Right at Home Northampton County was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
|